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Special Situations. Birth & Beyond California: Breastfeeding Training & QI Project With funding from the federal Title V Block Grant. Objectives. List three benefits of skin-to-skin care for preterm infants Identify three benefits of human milk for preterm infants

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special situations

Special Situations

Birth & Beyond California: Breastfeeding Training & QI Project

With funding from the federal Title V Block Grant


List three benefits of skin-to-skin care for preterm infants

Identify three benefits of human milk for preterm infants

Describe three nursing strategies to prevent hypoglycemia while supporting breastfeeding

List three breastfeeding-friendly jaundice treatments

List at least three contraindications to breastfeeding

Identify a reliable source of information regarding the compatibility of medications with breastfeeding


special babies and mothers need special nurse attachers
Special Babies and Mothers Need Special Nurse-Attachers!

Protect the mother-baby

Support the family with information

Provide anticipatory guidance

Nurture their dream

Believe in miracles


which babies are at risk of breastfeeding problems
Which Babies are at Risk of Breastfeeding Problems?

Preterm babies

Late preterm babies

Babies with hypoglycemia

Babies with hyperbilirubinemia (jaundice)


additional risk factors
Additional Risk Factors
  • Size issues:
    • SGA/LGA
    • Low birth weight
    • Multiples
  • Babies with infections 
  • Womb position and birth trauma
    • Torticollis, facial asymmetry


additional risk factors1
Additional Risk Factors
  • Congenital problems and defects: 
    • Heart conditions
    • Ankyloglossia (tongue tie)
    • Cleft lip & Cleft palate 


support intervention skin to skin
Support & Intervention: Skin-to-Skin

Skin-to-skin maintains the natural

habitat for the infant


benefits of the skin to skin for all at risk babies
Benefits of the Skin-to-Skin for All At-Risk Babies

Martinez, NeoReviews, 2007

  • Reduces stress hormones in infant
  • Stabilizes respiration
  • Reduces risk of hypothermia
  • Reduces risk of hypoglycemia
  • Helps baby function optimally


feeding options
Feeding Options
  • Breastfeed
    • Whenever possible
  • Breast milk
    • Using alternate feeding methods
  • Banked donor human milk
  • Artificial baby milk


four steps to breastfeeding success in difficult situations
Four Steps to Breastfeeding Success in Difficult Situations
  • Feed the baby
  • Establish & maintain the milk supply
  • Be sensitive to mother’s needs
  • Promote exclusive breastfeeding


preparation for discharge
Preparation for Discharge
  • Parent education and support
  • Hospital grade breast pump
  • Referral to
    • WIC
    • Community lactation consultant
    • Support services



Anderson, Cochrane Database, 2003

  • Skin-to-skin & human milk feeding

are preventive medicine

for premature babies


benefits of skin to skin for preterm babies
Benefits of Skin-to-Skin for Preterm Babies
  • Promotes physiologic stability
  • Promotes milk production & breastfeeding
  • Increases antibodies in mother’s milk
  • Increases parent confidence

Anderson, J Perinatol, 1991


benefits of human milk for preterm bab ies
Benefits of Human Milk for Preterm Babies
  • Improved feeding tolerance
  • Better growth & development
  • Improved cognitive outcome – higher IQ
  • Reduced risk of:
    • NEC
    • Sepsis & any infection
    • Allergy

Schanler,Acta Paediatr Suppl. 2005

Lucas, Lancet, 1992


helping mothers to initiate protect milk supply
Helping Mothers to Initiate & Protect Milk Supply


  • Provide resources for a hospital-grade electric breast pump with double kit to use at home
  • Recommend a pumping schedule:

8 sessions per 24 hours

    • option: plan one 4-5 hour interval between sessions during any 24 hour period to allow her time to rest
  • Follow NICU Guidelines


late preterm infants
Late Preterm Infants
  • Gestational Age 34-36 6/7 weeks
  • The imposter in the nursery
  • Often experience separation from mother
  • At increased risk for medical complications
  • Need time and help to successfully breastfeed

CPQCC, Care and Management of the Late Preterm Infant Toolkit, 2007 Engle, Pediatrics, 2007


helping mothers with transitioning into breastfeeding
Helping Mothers with Transitioning Into Breastfeeding
  • Skin-to-skin (kangaroo mother care)
  • Nose and mouth to nipple
  • Breastfeeding positions that emphasize neck/head stabilization
  • Practice Breastfeeding
    • “dry breastfeeding” milk transfer
    • part time breastfeeding / exclusive breastmilk
  • Exclusive Breastfeeding

Nyqvist, Acta Pediatrica, 2008


a premie needs his mother
A Premie Needs His Mother


by Jane Morton, MD



The process of teaching a preemie to breastfeed is not a straight line…

Based on the work of Berlith Person, Helsingborg Hospital, Sweden


Risk Factors :

  • Preterm, Post term, LBW
  • SGA, LGA
  • Infant of Diabetic Mother (IDM)
  • Stress
  • Use of Glucose
  • Multiples

Academy of Breastfeeding Medicine, Protocol #1

Revised 2006 www.bfmed.org


hypoglycemia definition and testing
Hypoglycemia: Definition and Testing
  • At this Hospital

hypoglycemia = glucose < ?

  • “Routine monitoring of asymptomatic, not

at-risk, term neonates is unnecessary.”

AAP, Pediatrics, 2005

Academy of Breastfeeding Medicine, Protocol #1, Rev. 2006


breastfeeding friendly hypoglycemia preventio n
Breastfeeding-Friendly Hypoglycemia Prevention
  • Skin-to-skin: Immediately after birth and throughout the first day
  • Breastfeed early: within the first hour
  • Breastfeed often: at least every 3 hours
  • Breastfeed long: without a time limit
  • Breastfeed well: assess latch and quality of suck


breastfeeding friendly hypoglycemia treatment
Breastfeeding – Friendly Hypoglycemia Treatment
  • Keep skin-to-skin
  • Breastfeed, then retest glucose level
  • If unable to breastfeed well:
    • Hand express or pump colostrum
    • Feed colostrum to baby
  • If unable to express more than a few drops:
    • Feed colostrum to baby
    • Supplement with formula


hyperbilirubinemia jaundice
Hyperbilirubinemia (Jaundice)


  • Pathologic
    • Blood incompatibility- ABO, Rh
    • Illness
  • Physiologic
    • Result of normal adaptive processes
    • Red Blood Cell (RBC) breakdown
  • Breastfeeding Associated
    • Infrequent, ineffective feedings
    • “Lack of breastfeeding” jaundice


Breastfeeding Frequency During the First 24 Hours After Birth and Incidence of Hyperbilirubinemia on Day 6

Study Conclusions

  • Early, frequent colostrum feeds accelerate meconium stooling
  • Feeding frequency reduced the incidence of hyperbilrubinemia

9+ feedings 0% jaundice on day 6

  • Exaggerated physiologic jaundice may be an early sign of breastfeeding difficulties

Yamauchi, Pediatrics, 1990


breastfeeding friendly jaundice treatment
Breastfeeding - Friendly Jaundice Treatment
  • Observe breastfeeding
    • Latch, quality of suck, energy level
  • Observe milk supply and milk transfer
    • Breast fullness, audible swallowing
  • Instruct mother to hand express and/or use breast pump
    • Supplement baby with expressed milk


triple feeding protocol
Triple Feeding Protocol
  • Breastfeed at least every 3 hours
    • Switch sides often
  • Supplement
    • With expressed milk if available
    • Use formula if necessary
    • Do not overfeed
  • Express milk
    • Save milk at room temperature
    • Use at next feeding or refrigerate


which mothers are at risk of breastfeeding difficulties
Which Mothers are at Risk of Breastfeeding Difficulties?

Social/educational factors

Lack of knowledge

Lack of support

  • Anatomy and physiology
    • Inverted/flat nipple
    • Too large/meaty nipples
    • Breast surgery
    • Hormone problems
    • Health conditions


contraindications for breastfeeding
Contraindications for Breastfeeding
  • Galactosemia
  • HIV (in U.S.)
  • HTLV-I & II
  • Untreated Tuberculosis
  • Herpes simplex lesion on a breast
  • Street drugs
  • Small number of medications

- Radioactive diagnostic isotopes

- Antimetabolites, chemotherapy

AAP, Pediatrics , 2005


not a contraindication
NOT a Contraindication
  • Hepatitis A, B, C
  • Maternal fever
  • Low level environmental contaminants
  • Maternal CMV carriers – term babies
  • Tobacco use
  • Occasional alcohol use

AAP, Pediatrics 2005


are these drugs safe to take while breastfeeding
Are These Drugs Safe to Take While Breastfeeding?
  • Magnesium Sulfate
  • Hydrocodone (Vicodin)
  • Ortho-Novum (Birth control pills)
  • Dicloxacillin or other antibiotic
  • Alcohol
  • Marijuana
  • Nicotine
  • Nitrofurantoin (Macrobid)

Hale, Medications and Mothers’ Milk, 2008


“It is well known that most medications

have few side effects in breastfeeding

infants because the dose transferred via

milk is almost always too low to be

clinically relevant, or it is poorly

bioavailable to the infant.”

Hale, Medications and Mother’s Milk, 2008


medications in mother s milk
Medications in Mother’s Milk
  • Reliable resources:
    • Briggs, Drugs in Pregnancy in Lactation, 2005
    • Hale, Medications in Mother's Milk, 2008
    • National Institute of Health: LactMed
      • www.toxnet.nlm.nih.gov


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